1. EHR Incentive Program and Meaningful Use Presentation to the Texas Association of Community Health Centers Deborah Norris Project Manager, Health IT Texas Medicaid and CHIP October 7, 2014

2. 2 Texas Medicaid EHR Incentive Program: Overview Eligible professionals (EPs) can receive incentives of up to $63,750 for the adoption and meaningful use of certified electronic health record (EHR) technology. First year payment can be from 2011 through 2016. Final payment can be received through the year 2021 for EPs. In the first of year of participation, EPs must adopt, implement, or upgrade (AIU) to a certified EHR. In subsequent participation years, they must demonstrate meaningful use (MU).

3. Eligible professional types: Physicians (M.D. or D.O.) Dentists Nurse Practitioners Certified Nurse Midwives Physician Assistants (PA) in federal qualified health centers (FQHCs) or rural health clinics (RHCs) led by a PA Doctors of Optometry (new in TX) Eligibility 3

4. Must meet 30 percent Medicaid volume threshold. Federally qualified health center (FQHC) providers can include CHIP and non-Medicaid “needy patient” encounters toward the 30 percent total. For MU: At least 50 percent of all encounters during MU reporting period must be at sites with certified EHR technology. Eligibility 4

5. FQHC Specific Requirements To attest as an FQHC provider, an EP must “practice predominantly” at an FQHC. This means: Over 50 percent of total encounters must be at an FQHC for a six-month period in the previous calendar year or in the preceding 12-month period. 5

6. FQHC Specific Requirements Physician Assistants (PA) only qualify if at an FQHC that is led by a PA, i.e. where a PA is: The primary provider in the clinic A clinical or medical director at the clinic The owner of the clinic If the FQHC is led by a PA, all PAs at that clinic may apply for EHR incentives. Note: all other eligibility requirements must be met. 6

7. Attestation Timeline: Eligible Professionals (EPs) complete Adopt, Implement, Upgrade (AIU) in the first year. Then 2 years of Stage 1 Meaningful Use (MU). Then 2 years of Stage 2 MU. Then Stage 3! Last year to start participating in the program is 2016. 7

8. Meaningful Use Requirements Healthcare providers must demonstrate Meaningful Use (MU) of their EHR. MU determined by scores on a list of metrics and meeting additional objectives. Metrics are heavily focused on capture of data in standardized, electronic format (Stage 1). Health information exchange (HIE) and patient engagement are also focus areas (Stage 2). Note: For the complete list of reportable measures, go to http://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html http://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html 8

9. Stage 1 vs. Stage 2 MU Stage 1 13 core measures 5 of 10 menu measures 18 total measures 6 of 48 CQMs Stage 2 17 core measures 3 of 6 menu measures 20 total measures 9 of 64 CQMs, from at least 3 domains Each EP attests individually to all MU measures. 9

10. Meaningful Use Measures MU data capture metric examples: Orders for meds, lab tests, radiology must be entered electronically and reported as necessary. Patient demographic data must be stored electronically. Certain data fields are specified as required. Diagnoses must be kept electronically and must be recorded as structured data to generate condition-specific patient lists. 10

11. Meaningful Use Measures Health Information Exchange MU examples: Transfer of immunization data from EHR to the state immunization registry via specified standards. Provide electronic copy (any format) of health information to patients (Stage 1). Patients have access to health information online and 5% of patients actually view, transmit, or download their health information (Stage 2). 11

12. Documentation Needed Some documentation required at time of attestation, e.g. proof of AIU (EHR contract, invoice, etc.) Encounter data to show 30 percent Medicaid/needy encounters. MU dashboard, screenshots, reports to support MU measures. Portal will guide you to upload necessary info. 12

13. Audits CMS requires states to audit providers. HHSC contracts with an independent audit firm AIU and MU audits occurring about 2 years after attestation, so keep all records!! Keep screenshots during your MU reporting period, showing various functionalities in use, e.g. drug- drug interaction checks, clinical decision support rule, drug formulary checks, etc. Keep EHR-generated reports that were used to calculate MU measures. 13

14. Audits Keep confirmation emails from Public Health registries demonstrating e-submission. Upload to portal, even if not required. Providers must maintain auditable records related to incentive program attestations for six years. 14

15. FQHC Organizational Participation 15

16. FQHC Provider Participation Where have all the EPs gone? 16

17. FQHCs – Incentives and Missed Opportunities Total incentives received* = $12,852,000 Total potential incentives* = $33,277,000 Missed opportunity* = $20,425,000 *estimates 17

18. FQHCs: Conversations with Texas RECs Texas has 4 Regional Extension Centers (RECs) that can provide Health IT technical assistance to individuals and organizations. We spoke with leadership at all 4 RECs for anecdotal info on FQHC participation in the EHR Incentive Program. Interesting variety of issues and challenges for FQHCs. 18

19. FQHC Barriers to Participation (based on conversations with RECs) Medicaid provider enrollment – lengthy process! Not enough staff resources to complete attestations. Internal management issues (not priority, disagreements about best approach, impatience with process) “Practice predominantly” requirement – many EPs work in multiple locations and don’t meet the 50 percent threshold. 19

20. FQHC Barriers to Participation (based on conversations with RECs) No Medicare penalties for FQHCs, so less pressure to move forward with MU. High staff turnover; EP attests at other clinic instead of FQHC. Workflow changes needed to meet measures – requires workplace culture change. 20

21. FQHC Technical Barriers (based on conversations with RECs) Big Problem: Regulations require upgrading to 2014 certified EHR software, but vendors are not ready! Some EHR software can’t accurately produce all the necessary MU reports. Vendors charge for separate MU modules, tech support, or other ‘upgrades’. Too expensive for FQHCs. FQHCs may not have an IT department or sufficient technical support. 21

22. FQHC Barriers to MU (based on conversations with RECs) MU Measures: Security Risk Assessment – no IT support to help do it Clinical Summaries – EPs don’t send them with in required timeframe Public health measures - Some vendors charge expensive connection fees to bridge to State immunization registry Electronic Summary/Transitions of Care – stricter for Stage 2 Patient Online Access to Info – requires portal and action by the patient (many FQHC clients don’t have regular internet access) Measures involving HIE (Stage 2) – need IT support 22

23. What Can You Do? Make MU a priority in your organization. Consider assigning dedicated staff to complete attestations and/or manage EHR program for your organization. Create an MU department with authority to revise workflows to meet measures. Seek out IT SMEs where possible. Work with RECs. Can provide technical assistance, audit support, and other services. Work with TACHC and engage with other FQHCs to share knowledge. 23

24. CMS Stage 2 Flexibility Rule (Sept 2014) Allows use of non-2014 certified software if EP cannot implement due to vendor issues. Applies to 2014 attestations only. Effective October 1, 2014. Flexibility will allow providers to receive incentives for 2014 using older versions of certified EHR software. Allows providers to attest to Stage 1 MU measures instead of Stage 2. Providers have until mid-March 2015 to apply for 2014 incentives. 24

25. H.R. 5481: Proposed Legislation U.S. House bill introduced on September 16, 2014. Would allow a meaningful use reporting period of 90 days in 2015 (similar to 2014), instead of 365 days of reporting. Flexibility would help some providers to meet MU. Must be passed by Congress. 25

26. Resources and Assistance 26

27. Web-based e-Learning Courses Web-based e-learning courses developed to educate users about the EHR Incentive program and how to attest. AIU courses for EPs and EHs. MU course for EPs. Free and available to public (not just Medicaid providers). Located at www.TexasEHRincentives.com.www.TexasEHRincentives.com 27

28. Health Information Technology Regional Extension Centers Contact the Regional Extension Center (REC) in your area for information on the support and assistance they can provide. Gulf Coast Regional Extension Center http://www.uthouston.edu/gcrec/index.htm CentrEast Regional Extension Center http://www.centreastrec.org/ North Texas Regional Extension Center http://www.ntrec.org/ West Texas Health Information Technology Regional Extension Center http://www.ttuhsc.edu/ http://www.ttuhsc.edu/ 28

29. Texas Association of Community Health Centers (TACHC) Private, non-profit membership association that represents safety-net health care providers in the state of Texas. TACHC provides support services, technical assistance and training for its members. http://www.tachc.org/ 29

30. Review program information on the CMS website: http://www.cms.gov/ehrincentiveprograms/. http://www.cms.gov/ehrincentiveprograms/ Review additional Texas Medicaid EHR Incentive Program information at: (http://www.tmhp.com/Pages/HealthIT/HIT_EHR.aspx).http://www.tmhp.com/Pages/HealthIT/HIT_EHR.aspx Sign up for e-mail updates at https://public.govdelivery.com/accounts/TXHHSC/subscriber/new and enter your email address. On the subscription topics page, go to the Projects section and select “Health Information Technology”. https://public.govdelivery.com/accounts/TXHHSC/subscriber/new For questions, contact EHR Incentive Program Business Services Center: HealthIT@tmhp.com or call 1-800-925-9126, option 4.HealthIT@tmhp.com Additional Resources 30

31. Questions: Texas Medicaid EHR Incentive Program 31